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Beyersdorf F. Innovation and disruptive science determine the future of cardiothoracic surgery. Eur J Cardiothorac Surg 2024; 65:ezae022. [PMID: 38243711 DOI: 10.1093/ejcts/ezae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
One of the currently most asked questions in the field of medicine is how any specialty in the future will evolve to ensure better health for the patients by using current, unparalleled developments in all areas of science. This article will give an overview of new and evolving strategies for cardiothoracic (CT) surgery that are available today and will become available in the future in order to achieve this goal. In the founding era of CT surgery in the 1950s and 1960s, there was tremendous excitement about innovation and disruptive science, which eventually resulted in a completely new medical specialty, i.e. CT surgery. Entirely new treatment strategies were introduced for many cardiovascular diseases that had been considered incurable until then. As expected, alternative techniques have evolved in all fields of science during the last few decades, allowing great improvements in diagnostics and treatment in all medical specialties. The future of CT surgery will be determined by an unrestricted and unconditional investment in innovation, disruptive science and our own transformation using current achievements from many other fields. From the multitude of current and future possibilities, I will highlight 4 in this review: improvements in our current techniques, bringing CT surgery to low- and middle-income countries, revolutionizing the perioperative period and treating as yet untreatable diseases. These developments will allow us a continuation of the previously unheard-of treatment possibilities provided by ingenious innovations based on the fundamentals of CT surgery.
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Affiliation(s)
- Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Germany
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Damjanovic D, Pooth JS, Liu Y, Frensch F, Wolkewitz M, Haberstroh J, Doostkam S, Cristina Schmitz HR, Foerster K, Taunyane I, Neubert T, Scherer C, Diel P, Benk C, Beyersdorf F, Trummer G. The Impact of Head Position on Neurological and Histopathological Outcome Following Controlled Automated Reperfusion of the Whole Body (CARL) in a Pig Model. J Clin Med 2023; 12:7054. [PMID: 38002667 PMCID: PMC10672538 DOI: 10.3390/jcm12227054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/27/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Introduction: Based on extracorporeal circulation, targeted reperfusion strategies have been developed to improve survival and neurologic recovery in refractory cardiac arrest: Controlled Automated Reperfusion of the whoLe Body (CARL). Furthermore, animal and human cadaver studies have shown beneficial effects on cerebral pressure due to head elevation during conventional cardiopulmonary resuscitation. Our aim was to evaluate the impact of head elevation on survival, neurologic recovery and histopathologic outcome in addition to CARL in an animal model. Methods: After 20 min of ventricular fibrillation, 46 domestic pigs underwent CARL, including high, pulsatile extracorporeal blood flow, pH-stat acid-base management, priming with a colloid, mannitol and citrate, targeted oxygen, carbon dioxide and blood pressure management, rapid cooling and slow rewarming. N = 25 were head-up (HUP) during CARL, and N = 21 were supine (SUP). After weaning from ECC, the pigs were extubated and followed up in the animal care facility for up to seven days. Neuronal density was evaluated in neurohistopathology. Results: More animals in the HUP group survived and achieved a favorable neurological recovery, 21/25 (84%) versus 6/21 (29%) in the SUP group. Head positioning was an independent factor in neurologically favorable survival (p < 0.00012). Neurohistopathology showed no significant structural differences between HUP and SUP. Distinct, partly transient clinical neurologic deficits were blindness and ataxia. Conclusions: Head elevation during CARL after 20 min of cardiac arrest independently improved survival and neurologic outcome in pigs. Clinical follow-up revealed transient neurologic deficits potentially attributable to functions localized in the posterior perfusion area, whereas histopathologic findings did not show corresponding differences between the groups. A possible explanation of our findings may be venous congestion and edema as modifiable contributing factors of neurologic injury following prolonged cardiac arrest.
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Affiliation(s)
- Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, D-79106 Freiburg, Germany
| | - Yechi Liu
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Fabienne Frensch
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Division Methods in Clinical Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, D-79104 Freiburg, Germany
| | - Joerg Haberstroh
- Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 66, D-79106 Freiburg, Germany
| | - Soroush Doostkam
- Institute of Neuropathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacherstr. 64, D-79106 Freiburg, Germany
| | - Heidi Ramona Cristina Schmitz
- Experimental Surgery, Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 66, D-79106 Freiburg, Germany
| | - Katharina Foerster
- Center for Experimental Models and Transgenic Service, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Stefan-Meier-Str. 17, D-79104 Freiburg, Germany
| | - Itumeleng Taunyane
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Tabea Neubert
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Patric Diel
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
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Wengenmayer T, Tigges E, Staudacher DL. Extracorporeal cardiopulmonary resuscitation in 2023. Intensive Care Med Exp 2023; 11:74. [PMID: 37902904 PMCID: PMC10616028 DOI: 10.1186/s40635-023-00558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/20/2023] [Indexed: 11/01/2023] Open
Affiliation(s)
- Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Eike Tigges
- Department of Cardiology and Critical Care, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Faculty of Medicine and Medical Center-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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Pooth JS, Liu Y, Petzold R, Scherer C, Benning L, Kreibich M, Czerny M, Beyersdorf F, Benk C, Trummer G, Brixius SJ. Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs. Biomedicines 2023; 11:2612. [PMID: 37892986 PMCID: PMC10604109 DOI: 10.3390/biomedicines11102612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
Controlled reperfusion by monitoring the blood pressure, blood flow, and specific blood parameters during extracorporeal reperfusion after cardiac arrest has the potential to limit ischemia-reperfusion injury. The intracellular calcium overload as part of the ischemia-reperfusion injury provides the possibility for the injury to be counteracted by the early suppression of serum calcium with the aim of improving survival and the neurological outcome. We investigated the effects of prolonged serum calcium suppression via sodium citrate during extracorporeal resuscitation using the CARL protocol (CARL-controlled automated reperfusion of the whole body) compared to a single-dose approach in a porcine model after prolonged cardiac arrest. A control group (N = 10) was resuscitated after a 20 min cardiac arrest, initially lowering the intravascular calcium with the help of a single dose of sodium citrate as part of the priming solution. Animals in the intervention group (N = 13) received additional sodium citrate for the first 15 min of reperfusion. In the control group, 9/10 (90.0%) animals survived until day 7 and 7/13 (53.8%) survived in the intervention group (p = 0.09). A favorable neurological outcome on day 7 after the cardiac arrest was observed in all the surviving animals using a species-specific neurological deficit score. The coronary perfusion pressure was significantly lower with a tendency towards more cardiac arrhythmias in the intervention group. In conclusion, a prolonged reduction in serum calcium levels over the first 15 min of reperfusion after prolonged cardiac arrest tended to be unfavorable regarding survival and hemodynamic variables compared to a single-dose approach in this animal model.
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Affiliation(s)
- Jan-Steffen Pooth
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Yechi Liu
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Ralf Petzold
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Christian Scherer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Leo Benning
- Department of Emergency Medicine, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (R.P.); (L.B.)
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Christoph Benk
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Georg Trummer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (Y.L.); (C.S.); (M.K.); (M.C.); (F.B.); (C.B.); (G.T.)
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VanZalen JJ, Harvey S, Hála P, Phillips A, Nakashima T, Gok E, Tiba MH, McCracken BM, Hill JE, Liao J, Jung J, Mergos J, Stacey WC, Bartlett RH, Hsu CH, Rojas-Peña A, Neumar RW. Therapeutic Effect of Argatroban During Cardiopulmonary Resuscitation and Streptokinase During Extracorporeal Cardiopulmonary Resuscitation in a Porcine Model of Prolonged Cardiac Arrest. Crit Care Explor 2023; 5:e0902. [PMID: 37181541 PMCID: PMC10174369 DOI: 10.1097/cce.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Prolonged cardiac arrest (CA) causes microvascular thrombosis which is a potential barrier to organ reperfusion during extracorporeal cardiopulmonary resuscitation (ECPR). The aim of this study was to test the hypothesis that early intra-arrest anticoagulation during cardiopulmonary resuscitation (CPR) and thrombolytic therapy during ECPR improve recovery of brain and heart function in a porcine model of prolonged out-of-hospital CA. DESIGN Randomized interventional trial. SETTING University laboratory. SUBJECTS Swine. INTERVENTIONS In a blinded study, 48 swine were subjected to 8 minutes of ventricular fibrillation CA followed by 30 minutes of goal-directed CPR and 8 hours of ECPR. Animals were randomized into four groups (n = 12) and given either placebo (P) or argatroban (ARG; 350 mg/kg) at minute 12 of CA and either placebo (P) or streptokinase (STK, 1.5 MU) at the onset of ECPR. MEASUREMENTS AND MAIN RESULTS Primary outcomes included recovery of cardiac function measured by cardiac resuscitability score (CRS: range 0-6) and recovery of brain function measured by the recovery of somatosensory-evoked potential (SSEP) cortical response amplitude. There were no significant differences in recovery of cardiac function as measured by CRS between groups (p = 0.16): P + P 2.3 (1.0); ARG + P = 3.4 (2.1); P + STK = 1.6 (2.0); ARG + STK = 2.9 (2.1). There were no significant differences in the maximum recovery of SSEP cortical response relative to baseline between groups (p = 0.73): P + P = 23% (13%); ARG + P = 20% (13%); P + STK = 25% (14%); ARG + STK = 26% (13%). Histologic analysis demonstrated reduced myocardial necrosis and neurodegeneration in the ARG + STK group relative to the P + P group. CONCLUSIONS In this swine model of prolonged CA treated with ECPR, early intra-arrest anticoagulation during goal-directed CPR and thrombolytic therapy during ECPR did not improve initial recovery of heart and brain function but did reduce histologic evidence of ischemic injury. The impact of this therapeutic strategy on the long-term recovery of cardiovascular and neurological function requires further investigation.
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Affiliation(s)
- Jensyn J VanZalen
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Stephen Harvey
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Pavel Hála
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Annie Phillips
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Takahiro Nakashima
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Emre Gok
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Mohamad Hakam Tiba
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Brendan M McCracken
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Joseph E Hill
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Jinhui Liao
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Joshua Jung
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Joshua Mergos
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI
| | - William C Stacey
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Cindy H Hsu
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
| | - Alvaro Rojas-Peña
- Department of Surgery and Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Surgery Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI
| | - Robert W Neumar
- Department of Emergency Medicine and The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan Medical School, Ann Arbor, MI
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Wisneski A, Smith JW, Nguyen TC, Fiedler AG. Molecules, Machines, and the Perfusate Milieu: Organ Preservation and Emerging Concepts for Heart Transplant. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:363-367. [PMID: 36271669 DOI: 10.1177/15569845221127305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew Wisneski
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Jason W Smith
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Tom C Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
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